Hysterosalpingography (HSG) is a contrast – enhanced x-ray gynecological examination used to check for possible abnormalities in the fallopian tubes and uterine cavity. Its most common indication is in the investigation of female infertility.
The procedure is simple, fast and has minimal possibilities for complications.
It is able to identify several gynecological problems, as it visualizes the anatomy of the female reproductive system from the uterus to the ovaries. The exam is performed by a radiologist and the patient is discharged on the same day.
HSG is performed to check for gynecological problems such as abnormalities in the uterus or uterine tubes, especially in patients who have difficulty conceiving.
The purpose of the exam is to assess the shape of the uterus and whether the tubes are obstructed, dilated or have an altered path, criteria that favor infertility.
It may also be requested by a gynecologist to investigate the cause of repeated miscarriages, which may result from congenital or acquired abnormalities in the uterus.
Changes in the uterus
Anatomical changes in the uterus are responsible for 10 to 15% of spontaneous abortions. The hysterosalpingography exam can be done to identify some problems in the region, such as:
- Uterine malformation;
- Polyps (excessive growth of cells in the walls of the uterus);
- Fibroids (benign tumors);
- Adenomyosis (growth of endometrial tissue within the muscle of the uterus);
- Uterus uni or bicorn;
- Didelphys uterus;
- Uterine synechiae (adhesions and scars).
After identifying the problem, some anomalies can be corrected with surgery.
Changes in the fallopian tubes
The fallopian tubes, or fallopian tubes, are two tubes of approximately 10 cm located one on each side of the uterus.
In the case of obstructions, fertilization is difficult when the egg is unable to come into contact with the sperm, in addition to the transport of the formed embryo to the uterus, an important function of the tubes.
The test can also help identify other possible causes for female infertility, such as:
- Hydrosalpinx (accumulation of fluid within the fallopian tubes);
- Blocking of the tubes due to infection or scarring;
- Closing and reopening of the tubes in a sterilization procedure;
- Tubal spasms.
If the patient has recently undergone tubal surgery, the doctor may order an HSG exam to verify that the operation was successful.
To perform hysterosalpingography, the patient lies in a gynecological position (belly up and with legs wide open) and the radiologist performs a quick examination of the pelvis to insert a vaginal speculum – an instrument used to dilate the entrance of the vagina. If necessary, an anesthetic injection can be applied to the cervix to relieve pain.
Then, a thin, flexible catheter is inserted into the orifice of the cervix, where a small amount of iodine contrast is injected. This contrast consists of a colored liquid that maps the organs as it travels through the female reproductive system, making it possible to view different angles of the uterine cavity and tubes through radiographs.
During the procedure, which lasts between 20 and 30 minutes, the doctor can ask the patient to change positions to move the liquid to specific places. Through this method, the radiologist is able to diagnose possible non-conformities of these structures.
After the examination, the catheter is removed and the patient is discharged to go home. If pain or cramping persists, the doctor should be consulted.
Hysterosalpingography should be performed one week after menstruation and before ovulation, between the 6th to the 12th day of the menstrual cycle. For patients who do not ovulate, HSG can be taken at any stage of the menstrual cycle.
The test should not be performed if the patient is already pregnant, as the iodinated contrast injected into the uterus and the X-ray may cause deformities in the fetus.
If you have a vaginal discharge or suspect a pelvic infection, the test should not be performed to prevent the contrast from taking bacteria into the uterus and tubes.
To ensure the effectiveness of the exam, patients must follow the following instructions before undergoing the procedure:
- Take a laxative prescribed by the doctor the night before the test is performed to empty the intestines and allow the uterus and surrounding structures to be clearly seen;
- Empty the bladder before the procedure;
- Inform the doctor about the possibility of being pregnant or suspected of being pregnant;
- Inform the doctor about the use of any medication;
- Report the existence of inflammatory or sexually transmitted diseases, such as chlamydia and gonorrhea;
- Warn about possible allergy to iodinated contrast;
- The metal can interfere with the X-ray machine, so it is necessary to remove any metal from the body before the examination, such as jewelry, metallic objects and clothing or removable devices;
- Avoid sexual intercourse a few days before and after the exam;
- Relax and stay calm, as anxiety can increase the perception of pain. It is recommended to perform the procedure in a doctor’s office indicated by a trusted doctor.
The processes used during HSG have evolved to less invasive techniques, with delicate and malleable equipment, in addition to water-soluble contrast, which has reduced the painful means that make many women still avoid the exam.
There are reports that, during the procedure, patients experience minimal discomfort similar to menstrual cramps, which last for around 5 minutes, in most cases. Some more sensitive patients may feel the pain persist for a few hours after the consultation ends.
As the exam is known to be painful and uncomfortable, laboratories must take the following fundamental precautions to make the patient tolerable and not compromise results:
- About 15 minutes before the test, administer an analgesic such as Buscopan or anti-inflammatory drugs to reduce the discomfort of colic. If necessary, the use of intravenous anesthetic may be recommended to provide more comfort through sedation;
- To prevent infections, an antibiotic can be administered before or after the procedure. The patient should not take drugs that were not prescribed by the doctor;
- The contrast used must be water-soluble, as it results in less risk of infection and less pain. To prevent the uterus from contracting, the fluid must be heated;
- Using a disposable plastic speculum instead of a metal one, as it is smaller and more flexible, reduces discomfort at the beginning of the examination;
- The laboratory should use a disposable catheter of thin and delicate thickness;
- The radiologist should avoid pinching the patient’s cervix, as it generates colic and even more severe symptoms, such as fainting and hypotension.
A feeling of internal heating may occur when the contrast is injected through the cervix. If there is an obstruction of the tubes, the patient may experience pain at the pressure point that the liquid comes into contact with the affected area. However, if the hysterosalpingography is performed carefully and the analgesic medication is taken correctly, the discomfort is well tolerated.
After the examination, the patient may experience abdominal cramps. To reduce uncomfortable symptoms, the doctor may prescribe anti-inflammatory drugs or pain relievers, such as dipyrone, scopolamine, paracetamol, among others.
Cramps and secretions or mild vaginal bleeding can also appear as post-examination symptoms. It is advisable to avoid the tampon in this situation.
Some women also experience dizziness and nausea after taking HSG. Generally, it is possible for women to return to their daily activities without further complications, as side effects are normal and will eventually disappear.
The indications vary according to the doctor, but some may indicate that the patient avoids sexual intercourse for a few days.
The patient need not worry about the injected contrast, as no residue remains in the body after the examination. She should only inform the doctor if she has symptoms of an allergy or infection, such as:
- Severe pain and cramps;
- Large amount of vaginal bleeding;
The radiologist, a doctor trained to supervise and interpret the radiology exams, is responsible for analyzing the images and sending a signed report to the doctor who ordered the exam, usually the gynecologist. From the result, the health professional can program the type of treatment or procedure to be applied for the condition that the patient is in.
If the HSG exam indicates a normal uterine shape and bilateral tubal permeability, the possibility of tubal obstruction or uterine malformation as causes of infertility is ruled out. Other gynecological problems may require additional tests for a specific diagnosis.
It is important to discuss the results with the doctor, as the difficulty in pregnancy can be caused by problems not assessed by hysterosalpingography, such as the low or abnormal sperm count of the man or the inability of a fertilized egg to implant in the uterus.
The normal shape of the uterus allows the contrast to spread normally after being injected, which does not occur in cases of the altered result. HSG can identify deformities in the uterus, with lumps or wounds.
Other tests may be necessary to help in the analysis of the gynecologist, but some diseases identified as a possible diagnosis are:
- Uterine malformation;
- Vaginal septum;
Fallopian tubes (fallopian tubes)
Hysterosalpingography can indicate tubes with malformation, inflammation or obstruction, which prevents the passage of contrast from the uterus to the end of the tubes. The causes of problems in the region can also be associated with other possible diagnoses, such as:
- Pelvic inflammatory disease.
The test cannot diagnose endometriosis , but it can show signs when there are images of tubal adhesions. It is also capable of indicating adenomyosis.
The patient should always consult with a specialist to obtain all possible details regarding the results of her examination.
As it is a diagnostic test, the main purpose of HSG is to find possible problems that hinder fertility. However, when there is a simple and small obstruction of the tubes, pregnancy can really happen.
There are reports of women who became pregnant weeks after the procedure, due to the unobstructed contrast and release of the tubes, which allowed fertilization. However, the situations are not common and pregnancy should not be the expected result when performing hysterosalpingography.
Pregnancy cases after the exam were more frequent when the contrast used was fat-soluble, which has a higher density. Due to the increased risk of allergy and complaints of pain, this type of contrast is no longer used.
HSG is a safe and non-invasive exam, as long as it is performed in specialized clinics and with qualified professionals.
In less than 1% of cases, infection in the uterus can occur. The chances increase in patients who have already had an incident of tubal and uterine lining infection or recent bacterial discharge.
Because of the contrast, the test presents a certain risk for patients with iodine allergy. Therefore, the physician must be advised of this allergy before performing hysterosalpingography. In case of allergic reactions, swelling or itching in the region after the examination, the health professional should also be informed.
As the procedure uses low radiation, it does not cause harmful damage to the patient, even if she becomes pregnant a few weeks after undergoing HSG. However, it should not be performed during pregnancy, as it can be dangerous for the fetus.
The price of hysterosalpingography is around 500 reais, with variations depending on the health plan or the selected clinic. There is also the possibility of scheduling the exam at a SUS health unit.
Hysterosalpingography analyzes only the interior of the uterus and fallopian tubes to check for abnormalities, whereas other pelvic structures are assessed using complementary procedures.
Depending on the result, the health professional may request additional tests to have a complete diagnosis of the causes of the anatomical problems seen in HSG.
The complementary exams that can be requested are:
Video laparoscopy (laparoscopy)
About 15% of patients show erroneous results in cases of tubal changes. This is because there may be contraction of the local smooth muscle, causing the contrast to fail to pass from the uterus to the tubes, distorting the results.
In this situation, another exam is necessary to confirm a tubal obstruction, and videolaparoscopy with chromotubation is indicated – minimally invasive surgery performed through pelvic punctures.
If previous tests have failed to reveal the causes of infertility or recurrent miscarriages, healthcare professionals may order a hysteroscopy to obtain more details about the results of the hysterosalpingography.
Hysteroscopy is a procedure that inspects the uterus using a small camera inserted in the region, allowing for a more detailed analysis.
This examination is necessary to find abnormalities in the shape of the uterus in 35% of cases of normal or inconclusive HSG results. However, he is unable to assess the tubes or identify whether they are blocked.
Hysterosalpingography is a short procedure capable of providing valuable information that helps to diagnose a variety of abnormalities that cause infertility.
Because of the fear of feeling pain, the exam has always brought fear to most women who think about doing it. However, the use of new equipment has greatly reduced the risks and discomfort experienced by patients.
Always remember to consult a trusted professional before scheduling the procedure, as only a specialist will be able to tell you the best exam and treatment indicated for your situation.
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